Full-Thickness and Unstageable Pressure Injuries That Develop in Nursing Home Residents Despite Consistently Good Quality Care

PURPOSE: The purpose of this study was to determine whether stage 3, 4, and unstageable pressure injuries develop despite consistently good quality care (CGQC); ascertain whether these wounds occur without prior recognition of a lower-stage pressure injury; and to describe and analyze characteristics of nursing home residents and their higher-stage pressure injuries. DESIGN: Descriptive, nonexperimental, prospective analysis. SUBJECTS AND SETTING: A convenience sample of 20 residents from facilities participated in the study; research sites were located in 7 counties in Western Washington and Orange County, along with a single site in Wisconsin. METHODS: CGQC facilities were identified using a 3-step incremental approach. Research assistants verified CGQC at the facility level. After data collection was complete, a Longitudinal, Expert, All-Data Panel reviewed cases for a final resident-level validity check for CGQC. Remaining cases were submitted to analysis. RESULTS: Residents who developed advanced stage pressure injuries despite CGQC were older, had limited mobility, dementia, comorbid conditions, urinary or fecal incontinence, and infections. The pressure injuries were relatively small and had little-to-no undermining, exudate, or edema. CONCLUSIONS: Stage 3, 4, and unstageable pressure injuries were observed in nursing home residents despite CGQC. Results from this study may serve as a baseline for further research to evaluate characteristics of these wounds when they develop under settings of poor-quality care. Findings also may be useful in creating evidence-based practice guidelines to support decision making around mandatory reporting, diagnosis, and prosecution.